epidemiologists would agree that the purpose of epidemiology is to
investigate the causes of disease to improve public health. In a
surprisingly candid observation made during his opening
Presidential Address at the recent SER meeting in Boston, Columbia
University’s Sandro Galea, Chairman of the Department
of Epidemiology, told epidemiologists in attendance “we are
seeing a gross failure in our improving the health of
Contributing to this failure, according to Galea,
is the excessive focus on etiologic questions and a dearth of
research centered on approaches to disease control and prevention.
As a result of this imbalance, he added, epidemiologists are not
only failing to make an impact on population health, but
epidemiology is falling out of favor with the National Institutes
of Health, the primary funder of epidemiologic research.
Galea called for a
consequentialist epidemiology which gives more weight to questions
that have a greater chance of making a difference in population
In reminding the
audience that the discipline is not only about investigating the
causes of disease but also doing something about them, he echoed
the concept of “consequential epidemiology” first coined by
Bill Foege in a Wade Hampton Frost Lecture in 1983 and
repeated in a 1994 SER Presidential Address by Ward Cates.
Foege described epidemiology as a tool to change the world-- not
only to study the world. Cates said epidemiologists make their
work consequential by asking “so what?” about the impact of
epidemiologic findings and “how much?” about the cost of health
Finding that epidemiologists have failed to improve
population health is a serious conclusion and Galea backed up his
assertions with several
First, to establish the excessive focus on etiologic research,
Galea investigated all papers published in 2012 in the four
leading epidemiology journals. “We found that 85% of papers in
these journals can be reasonably considered papers concerned with
etiology or with efforts to help deal with causes,” he said.
To back up his
assertion that epidemiologists are not able to impact the problems
of population health, he cited a recent Institute of Medicine
study that showed the US lags behind nearly all high income
countries on 9 important indicators of population health despite
spending more on health care than any of these other countries.
“This is exactly what is in our remit to tackle, to help do
something about, and, well, someone, maybe it’s us, maybe it’s
not, is failing.”
Galea said, is “a recalibration of what we do.” In calling for
more research focused on questions that lead directly to doing
something to improve population health, he used the example of
firearm deaths to make his point. He called these deaths
“outrageous calamities” and saying “there is no way to countenance
this from within a discipline that is concerned with the promotion
of health.” He added, “we should run, not walk, to a research
agenda that addresses these issues.”
Galea concluded by
saying that embracing a more consequentialist epidemiology would
have epidemiologists doing a few things differently, including:
1. It would have
epidemiologists looking for “big wins” such as that which occurred
with the reduction in motor vehicle deaths. Can we show the same
curve for firearm deaths in 20 years? In 50 years? he asked.
2. It would have
epidemiologists spending a lot less time arguing about what scope
and methods constitute epidemiology. Instead, epidemiologists
would be focused simply on methods that improve population health
while rejecting those that do not.
3. It would have
epidemiologists more focused on the health of populations
wherever there is
a need to do so. This would mean “Think Globally and Work
Globally” because that is where the problems are greatest and
where associated challenges around equity and efficiency are
4. It would have epidemiologists embrace translation and
implementation science. These topics are an effort by the federal
government to make a difference, said Galea, and epidemiologists
should participate in it.
5. It would have epidemiologists getting away from
teaching students the canon of methods and how we apply them, to
teaching students from first principles with encouragement to take
on epidemiology as the science of population health with an
explicit and express intent to improve population health.
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